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WORKER'S
COMPENSATION QUESTIONNAIRE
- For
your convenience Tashjian Insurance Agency, Inc. keeps their
fax lines open at all times. Please print out this sheet and fax it
to 626.357.5037
Contact
Information:
- Contact
Name:
- Business
Name:
- Contact
Phone: E-Mail Address:
- Street
Address:
- City:
State:
Zip Code:
- Business Description:
- Number of Years in Business:
Employee Information:
- Total Number of Employees:
Total Annual Payroll:
- Number of office Employees:
Office Employee Payroll:
- Number of Outside Sales
Personnel:
Outside Sales Payroll:
- Number of Employee Injuries
in Past Three Years:
COMMENTS/REMARKS:
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